VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Havenwood
50 Havenwood Drive
Lexington, VA 24450
(540) 463-2205

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Nov. 8, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/08/2023 8:45AM until 1:30PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration, medication cart audit, noon-time meal, activities An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-190-C
Description:	Based on staff record review and staff interview, the facility failed to ensure the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities prior to being placed in charge. EVIDENCE: 1. During on-site inspection on 11/08/2023, two licensing inspectors (LIs) noted that staff person 1 was in charge at the state of the inspection. Interview with staff person 4 confirmed that staff person 1 was in charge. 2. The record for staff person 1 did not contain documentation that they had been informed of and received training on their duties and responsibilities and provided written documentation of such duties and responsibilities prior to being placed in charge. Interview with staff person 4 confirmed that this was accurate.
Plan of Correction:	Documentation for person in charge was corrected on 11/8/2023. Administrator will ensure this documentation is in hire packet when new employees come to make sure this is signed and in employees chart and is understood by employees.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review and staff interview, the facility failed to ensure verification that a staff person has received a copy of their current job description. EVIDENCE: The records for staff persons 1, 2 and 3 did not contain verification that they have received a copy of their current job description. During an interview with two licensing Inspectors (LIs) and staff person 4, staff person 4 confirmed that this was accurate.
Plan of Correction:	Staff records with job duty description was corrected on 11/8/2023. Administrator will ensure this documentation is in hire packet when new employees come to make sure this is signed and in employees chart and is understood by employees.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review and staff interview, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician that contains the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: Resident 2 was admitted to the facility on 10/18/2023; however, a TB screening was not completed on the resident until 10/26/2023. Interview with staff person 4 during on-site inspection on 11/08/2023 confirmed that this was accurate.
Plan of Correction:	Administration and nursing staff will verify all documents before the residents arrival date to ensure that all required documentation is at the facility preceding arrival and before admission.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed as required by 22VAC30-110 which states sections of the UAI shall be completed such as functional status, which includes Activities of Daily Living. EVIDENCE: 1. The UAI in the record for resident 4, dated 04/17/2023, indicates that the resident requires assistance with bathing, dressing, toileting, transferring, eating, and mobility; however, the UAI does not indicate the level of functioning to determine what assistance is needed. 2. During an interview with two licensing inspectors (LIs) and staff person 4, staff person 4 acknowledged that the UAI had not been completed in its entirety for these functional status areas for resident 4.
Plan of Correction:	UAI for resident 4 corrected on 11/8/2023. Administration will double check all UAI over twice to make sure no spaces are left blank.
Standard #:	22VAC40-73-440-H
Description:	Based on resident record review and staff interview, the facility failed to ensure that annual reassessments, using the Uniform Assessment Instrument (UAI), shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. EVIDENCE: 1. During on-site inspection on 11/08/2023, the record for resident 3 contained a UAI dated 09/15/2022. 2. During an interview with two licensing inspectors (LIs) and staff person 4, staff person 4 revealed that this was the most recent UAI for resident 3 and that an updated UAI has not been completed for the resident as of on-site inspection.
Plan of Correction:	Resident 3 UAI updated on 11/8/2023, Administrator will keep list of residents UAI paperwork to ensure they are updated yearly as required.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organizations shall communicate and establish an agreed upon coordinated plan of care for the resident and the services provided by the hospice organization shall be included on the individualized service plan (ISP). EVIDENCE: 1. The record for resident 4 contains a physician?s order, dated 09/19/2023, from a hospice agency for an assisted living facility comfort kit and a nutrition assessment note from a registered dietitian, dated 10/20/2023, that the resident is on hospice. Interview with staff person 4 confirmed that resident 4 is on hospice. 2. The ISP in the record for resident 4, dated 04/17/2023, does not indicate that the resident is on hospice.
Plan of Correction:	ISP for resident 4 updated on 11/8/2023 by adding hospice services to care plan and reviewed with family on 11/15/2023. Administrator and nursing staff will ensure all care plans are updated yearly and when new services or changes occur.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan). EVIDENCE: The ISP in the record for resident 2 during on-site inspection on 11/08/2023, dated 10/19/2023, had not been signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan).
Plan of Correction:	Administrator signed on 11/8/2023 Administrator will make sure documentations are signed when reviewed with resident and their families.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months. EVIDENCE: 1. During on-site inspection on 11/08/2023, the record for resident 3 contained an ISP dated 09/15/2022. 2. During an interview with two licensing inspectors (LIs) and staff person 4, staff person 4 revealed that this was the most recent ISP for resident 3 and that an updated ISP has not been completed for the resident as of on-site inspection.
Plan of Correction:	ISP for resident 3 updated on 11/8/2023 and reviewed with family on 11/15/2023. Administrator and nursing staff will ensure all care plans are updated yearly and when new services or changes occur.
Standard #:	22VAC40-73-950-E
Description:	Based on staff interview, the facility failed to ensure to implement a semi-annual review on the emergency preparedness and response plan for all residents with an emphasis placed on an individual?s respective responsibilities. EVIDENCE: Interview with staff person 4 during on-site inspection on 11/08/2023 revealed that a semi-annual review of the facility?s emergency preparedness and response plan has not been conducted during 2023 with residents.
Plan of Correction:	Administrator has reached out to emergency management coordinator on November 14, 2023 for the area to work on better emergency plan for both staff and residents.
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interview, the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51) and the drills required for each shift in a quarter shall not be conducted in the same month. EVIDENCE: The document, record of required fire and emergency evacuation drills, provided to the licensing inspector (LI) by staff person 4 during on-site inspection on 11/08/2023, indicates that the facility has not conducted a fire and emergency evacuation drill since 07/27/2023. Interview with staff person 4 confirmed that this is accurate.
Plan of Correction:	Administrator has reached out to emergency management coordinator on November 14, 2023 for the area to work on better emergency plan for both staff and residents.